Sports Medicine Feature

Weight Gain Key to Healing Stress Fractures

Biloine W. Young • Tue, October 3rd, 2017

An Ohio State University (OSU) study led by Timothy L. Miller, M.D. spent three years studying the relationship between stress fractures and the time it took for an injured Division I athletes to return to running.

They found that the lower the athlete’s body mass index (BMI) the longer it took to heal. For runners, being skinny is not better.

The OSU study identified 24 tibial stress fractures in 18 women. The researchers took into consideration the grade of the stress fractures using the K-M system. “This is a unique classification method because it considers both radiographic and clinical evidence,” Miller said.

A Grade I is a stress reaction that appears only on radiographic results and does not cause pain. Grade V is a nonunion stress fracture. “These are injuries that the patients have ignored or mistreated, and surgery may be needed to repair them,” Miller said. “Essentially, the body has given up trying to heal these fractures.”

The research team found that the average time required to return to running for those with a Grade V injury was 17 weeks, compared with 13.7 in grades II and III. The researchers also found that the women with BMIs lower than 19 were at a higher risk to develop stress fractures than were their heavier running mates.

Miller says that there is a problem among female collegiate runners because of their widely held belief that lighter equals faster. “Staying at a low weight may work for a while,” he says, “but eventually, it catches up to these athletes and they end up injured.”

Miller suggests that thin runners add lean muscle mass to support their bones. “To do this, these runners may gain weight and their BMIs will go up,” he says. “But it will help keep them healthier and in the game.”

Lt. Col. Mark Cucuzzella, a professor at West Virginia University School of Medicine, says female runners with low BMIs should be aiming to add fat to their bodies. “In this age group, body fat should be in the range of 20 percent to 22 percent for hormonal health,” he says. “If it’s not there, all the calcium and vitamin D in the world won’t heal a stress fracture.”

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Higher BMI Helps Heal Stress Fractures

Biloine W. Young • Fri, June 23rd, 2017

An Ohio State University (OSU) study led by Timothy L. Miller, M.D., spent three years studying the relationship between stress fractures and the time it took for the injured athlete to return to running on a Division 1 team. They found that the lower the athlete’s body mass index (BMI) the longer it took to heal.

For runners, being skinny is not better.

The OSU study identified 24 tibial stress fractures in 18 women. The researchers took into consideration the grade of the stress fractures using the K-M system. “This is a unique classification method because it considers both radiographic and clinical evidence,” Miller said.

A Grade I is a stress reaction that appears only on radiographic results and does not cause pain. Grade V is a nonunion stress fracture. “These are injuries that the patients have ignored or mistreated, and surgery may be needed to repair them,” Miller said. “Essentially, the body has given up trying to heal these fractures.”

The research team found that the average time required to return to running for those with a Grade V injury was 17 weeks, compared with 13.7 in grades II and III. The researchers also found that the women with BMIs lower than 19 were at a higher risk to develop stress fractures than were their heavier running mates.

Miller says that there is a problem among female collegiate runners because of their widely held belief that lighter equals faster. “Staying at a low weight may work for a while,” he says, “but eventually, it catches up to these athletes and they end up injured.”

Miller suggests that thin runners add lean muscle mass to support their bones. “To do this, these runners may gain weight and their BMIs will go up,” he says. “But it will help keep them healthier and in the game.”

Lt. Col. Mark Cucuzzella, M.D., FAAFP, a professor at West Virginia University School of Medicine, says female runners with low BMIs should be adding fat to their bodies. “In this age group, body fat should be in the range of 20 percent to 22 percent for hormonal health,” he says.

Obesity Factor in Ankle Fractures

Biloine Young • Mon, November 26th, 2012

It should not come as a surprise, but research published in the Journal of Foot and Ankle Surgery has found that being obese nearly doubles the odds of a patient having an ankle fracture of the most severe category. Researchers, in their study of 280 patients, explored the association between obesity and the severity of ankle fractures. They analyzed the X-rays of each patient’s ankle fracture, classified the severity of each injury, took into account each patient’s body mass index (BMI), age, tobacco use, sex and whether or not they were diabetic or had osteoporosis.

The researchers found that being overweight or obese was associated with an increased risk of musculoskeletal problems. The increase in weight also has grave effects on the bone and joints, increasing the risk of osteoarthritis and (potentially) the need for total joint replacement at a younger age.

They found a strong correlation between more severe ankle fractures and obesity, especially for obese men younger than 25, and obese women older than 50. Alan MacGill, M.D., a Florida foot and ankle surgeon said, "We are seeing more severe injury patterns in the obese population compared to the non-obese. These severe ankle fractures tend to have a worse prognostic outcome compared to others."

He added, "The findings of this study correlate with what I continue to see in my practice. It's basic physics; as body mass increases, so does the kinetic energy associated with the injury. The higher the body mass, the greater the risk of more severe ankle injury."

Study Shows How Binge Drinking Slows Bone Health

Elizabeth Hofheinz, M.P.H., M.Ed. • Wed, October 9th, 2013

Inebriated mice are leading the way toward information on drunkenness and fracture healing. A team of researchers from Loyola University Medical Center has found new information on how alcohol slows healing on the cellular and molecular levels. The findings could lead to treatments to improve bone healing in alcohol abusers, and possibly non-drinkers as well.

Roman Natoli, M.D., Ph.D. has just presented these findings at the American Society for Bone and Mineral Research 2013 Annual Meeting in Baltimore. Senior author is John Callaci, Ph.D. The study was funded by the Orthopaedic Research and Education Foundation.

“Many bone fractures are alcohol-related, due to car accidents, falls, shootings, etc., ” Dr. Natoli said in the October 7, 2013 news release. “In addition to contributing to bone fractures, alcohol also impairs the healing process. So add this to the list of reasons why you should not abuse alcohol.”

Researchers studied the effects that alcohol consumption had on bone healing in mice. One group of mice was exposed to alcohol levels roughly equivalent to three times the legal limit for driving. A control group was exposed to equal amounts of saline.

The study found three ways in which alcohol impaired bone healing after a fracture: There were differences between the control group and the alcohol-exposed group in the callus, the hard bony tissue that forms around the ends of fractured bones. In the alcohol-exposed group, the callus was less mineralized, meaning not as much bone was forming. Moreover, the bone that did form was not as strong.

Mice exposed to alcohol showed signs of oxidative stress, a process that impairs normal cellular functions. The alcohol-exposed mice had significantly higher levels of malondialdehyde, a molecule that serves as a marker for oxidative stress. Additionally, levels of an enzyme that decreases oxidative stress, super oxide dismutase, were higher in the alcohol-exposed mice (but not quite high enough to be considered statistically significant).

During the healing process, the body sends immature stem cells to a fracture site. After arriving at the site, the stem cells mature into bone cells. Two proteins, known as SDF-1 and OPN, are involved in recruiting stem cells to the injury site.

Study Challenges How Bone Fractures Heal

Biloine W. Young • Thu, January 7th, 2016

When a study demolishes a century-old belief about how fractured bones heal, it is labeled a “breakthrough.”

That is what researchers at Vanderbilt University have achieved in their discovery that fibrin is not essential to bone healing—as everyone once thought. It turns out that it is the breakdown and clearance of fibrin that is essential to the healing process. Tiffany Parnell wrote in MDNews that the Vanderbilt study “alters a century-old belief about bone fracture healing.”

As Parnell explained, when a bone is broken and normal vasculature is disrupted, the enzyme thrombin converts fibrinogen to fibrin. Fibrin is an insoluble protein that forms a fiber mesh at the site of the injury. Because doctors found fibrin present at every site of a bone fracture they believed, for a hundred years, that the fibrin was forming the scaffold for the bone to heal.

Not so, writes Jonathan Schoenecker, M.D., Ph.D., assistant professor of Orthopaedics, Pharmacology, Pathology and Pediatrics at the Vanderbilt Center for Bone Biology and senior author of the Journal of Clinical Investigation-published study.

It all began when Schoenecker received a grant to demonstrate the mechanism by which fibrin heals bone fractures. Orthopedic surgeons are concerned about their patients getting deep vein thrombosis. To prevent it they often prescribe anticoagulants. The researchers suspected that anticoagulant use may interfere with fibrin production.

“There’s a lot of data that suggests that the use of anticoagulants has a negative effect on healing tissue, ” Schoenecker said. “Going into this project, the assumption was that the reason why patients were having a hard time healing their fractures or wounds was because we were reducing the amount of fibrin that was laid down. We thought that the template [for healing] wasn’t there.”

Schoenecker and his team of researchers from the Schoenecker Lab at Monroe Carell Jr. Children’s Hospital at Vanderbilt hoped to determine how much fibrin was necessary to heal a fracture. Their goal was to find the dosage at which anticoagulants are effective at preventing thrombosis but do not deplete fibrin levels to the point that normal wound healing would be disrupted.

Oxidative Stress Predicts Hip Fracture

Elizabeth Hofheinz, M.P.H., M.Ed. • Wed, August 27th, 2014

Researchers from the University of Cincinnati (UC), Harvard School of Public Health, and Harvard Medical School have found that oxidative stress is a significant predictor for hip fracture in postmenopausal women. The study appears online ahead of print in the Journal of Bone and Mineral Research.

The research was led by Tianying Wu, M.D., Ph.D., an assistant professor in the UC College of Medicine Department of Environmental Health, and Shuman Yang, a postdoctoral fellow in the department. The team evaluated participants from the Nurses’ Health Study, and measured oxidative stress by noting fluorescent oxidation products (FlOP) in blood plasma.

“To our knowledge, this is the first prospective study among postmenopausal women demonstrating that oxidative stress was a significant predictor for hip fracture, ” said Dr. Wu in the August 14, 2014 news release.

According to the news release, a total of 996 women aged 60 or older were measured at baseline blood collection (1989-1990). “Plasma FlOPs were measured at three excitation/emission wavelengths: 360/420 nm (nanometers), named as FlOP_360; 320/420 nm, named as FlOP_320; and 400-475 nm, named as FlOP_400. FlOP_360 represents oxidation products that are generated from oxidized phospholipids or from lipid oxidation products reacting with proteins. FlOP_320 is formed when oxidation products such as lipid hydroperoxides, aldehydes and ketones react with DNA in the presence of metals. FlOP_400 reflects the interaction between malondialdehyde (a specific marker for lipid oxidation), proteins and phospholipids.”

“Of the three wavelengths, researchers found that baseline levels of FlOP_320 products predicted risk of future hip fracture in the study cohort. (No association was found with FlOP_360 and FlOP_400.) Increased FlOP_320 was associated with greater risk of hip fracture; women in the upper 30% of FlOP_320 readings were found to have 2.67 times the risk of hip fractures of those in the bottom 30%.”

“Because FlOP_320 is generated in the presence of metals, its strong association with hip fractures may reflect the co-existing effect of reactive oxygen species and heavy metals, ” says Dr. Wu, who notes that the other FlOP products can be generated without metals.

Dr. Wu told OTW, “If our results are confirmed in larger studies, FlOP_320 may potentially used as a marker for screening individuals are at risk for hip fracture in addition to DEXA scan.”